What is CTEPH, and what is BPA?
Chronic thromboembolic pulmonary hypertension develops when blood clots from a pulmonary embolism don’t fully resolve. Over months and years, the residual clot becomes organized scar tissue that narrows or blocks the pulmonary arteries. Pressure inside the lung circulation rises, the right ventricle becomes strained, and patients describe progressive shortness of breath, fatigue, exercise intolerance, and sometimes chest pain or fainting. The diagnosis is confirmed by a multidisciplinary CTEPH team using ventilation/perfusion scanning, CT pulmonary angiography, and right heart catheterization.2
Balloon pulmonary angioplasty is an image-guided procedure that opens narrowed pulmonary arteries from inside the vessel. Through a small access in a vein, an interventional radiologist threads a thin catheter into the pulmonary arteries and gently inflates a small balloon at each narrowed segment. Treatment is delivered across multiple staged sessions to safely improve blood flow without overloading the lungs all at once. For patients whose disease is not amenable to surgery — or who have residual disease after surgery — BPA has become an established, guideline-recommended option.
Why this approach
For decades, the only definitive treatment for CTEPH was a major operation called pulmonary endarterectomy (PEA), performed on cardiopulmonary bypass by a small number of specialized cardiothoracic surgeons. PEA is still the first-line treatment when feasible, and it can be curative. But many patients — because of where the disease sits in the pulmonary tree, other health conditions, or persistent disease after PEA — are not surgical candidates. BPA gives those patients a real, image-guided treatment option that didn’t exist a generation ago.3
How the procedure works
BPA is performed in a hospital cardiac or interventional suite, usually under local anesthesia with light sedation. A small catheter is inserted through a vein, typically at the groin or neck, and guided into the right side of the heart and on into the pulmonary arteries under live X-ray imaging. Selective contrast injections map exactly which segments are diseased.
Once a target lesion is identified, a small balloon catheter is advanced and gently inflated to open the narrowing. Several lesions are typically treated in one session, but the full course is delivered across four to six sessions, spaced weeks apart — a deliberate pace that gives the lungs and right heart time to adjust safely and minimizes the risk of reperfusion injury.4 Each session usually lasts 90 to 120 minutes. Most patients are observed overnight after each session and go home the following day.
Who is a good candidate?
BPA is offered as part of a coordinated, multidisciplinary CTEPH program. You may be a candidate if any of the following apply:
- Inoperable CTEPH — your disease is too far out in the pulmonary tree, or too diffuse, for surgery to reach safely
- Residual or recurrent pulmonary hypertension after pulmonary endarterectomy — your numbers and symptoms haven’t normalized after PEA
- You’re not a surgical candidate for PEA because of other health conditions or surgical risk
- You have chronic thromboembolic disease (CTED) with limiting symptoms despite normal resting pressures, in selected cases reviewed by the CTEPH team
Candidacy is determined by the multidisciplinary CTEPH team — pulmonary hypertension specialists, cardiothoracic surgeons, cardiology, hematology, and interventional radiology — based on your imaging, hemodynamics, and overall picture.
Medical therapy and anticoagulation
BPA is not a replacement for medical therapy. Most patients with CTEPH continue lifelong anticoagulation to prevent new clots, and many continue PH-specific medications such as riociguat (a soluble guanylate cyclase stimulator) as decided by their pulmonary hypertension specialist. Anticoagulation, PH medications, and the cadence of follow-up are managed by the PH specialist and hematologist; BPA is the procedural component of a broader plan, not a substitute for it.
What to expect from treatment
The goal of BPA is to lower pulmonary artery pressure, improve right heart function, increase exercise tolerance, and reduce shortness of breath. Outcomes are tracked across the full course of treatment with serial right heart catheterization, six-minute walk testing, NT-proBNP, and functional class assessment. In experienced multidisciplinary CTEPH programs, published series report substantial reductions in mean pulmonary artery pressure and pulmonary vascular resistance, along with measurable improvements in exercise capacity. Improvement is typically gradual across the four-to-six-session course rather than immediate after a single visit.
Who performs BPA
BPA is performed by interventional radiologists and interventional cardiologists with specific training in pulmonary vascular procedures, working as part of a multidisciplinary CTEPH program. At Florida Interventional Specialists, every BPA case is delivered in close partnership with the referring pulmonary hypertension specialist, cardiology team, cardiothoracic surgery program, and hematology — because CTEPH care done well is always team care.
References
- Ende-Verhaar YM, Cannegieter SC, Vonk Noordegraaf A, et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature. Eur Respir J. 2017;49(2):1601792.
- Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2023;61(1):2200879.
- Mahmud E, Madani MM, Kim NH, et al. Chronic thromboembolic pulmonary hypertension: evolving therapeutic approaches for operable and inoperable disease. J Am Coll Cardiol. 2018;71(21):2468–2486.
- Brenot P, Jaïs X, Taniguchi Y, et al. French experience of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Eur Respir J. 2019;53(5):1802095.
Frequently asked questions
What is CTEPH?
CTEPH stands for chronic thromboembolic pulmonary hypertension. It develops when a blood clot in the lungs (pulmonary embolism) doesn’t fully dissolve. Over time, the residual clot becomes scar tissue that narrows the pulmonary arteries, blood pressure in the lungs rises, and the right side of the heart becomes strained. CTEPH is rare but treatable — and is widely under-recognized.
How is BPA different from pulmonary endarterectomy (PEA)?
Pulmonary endarterectomy is open surgery on cardiopulmonary bypass that physically removes the chronic clot. It is still the first-line treatment when feasible. BPA is a minimally invasive, image-guided alternative for patients whose disease is too distal for surgery, who are not surgical candidates, or who have persistent pulmonary hypertension after PEA. Some patients benefit from a combined approach — surgery for the more central disease and BPA for residual distal disease.
How many BPA sessions will I need?
Most patients require four to six staged sessions, spaced weeks apart. Treating only a few segments per session helps avoid reperfusion injury and allows the lungs and right heart to adjust gradually.
Will I still need pulmonary hypertension medications after BPA?
Most patients continue lifelong anticoagulation, and many continue PH-specific medications such as riociguat as decided by their pulmonary hypertension specialist. BPA is not a substitute for medical therapy — it’s the procedural part of a coordinated multidisciplinary plan.
Is the procedure painful?
BPA is performed under local anesthesia with light sedation. Most patients describe pressure rather than pain. Some chest discomfort or cough during balloon inflations is common and resolves quickly. Mild soreness at the access site is typical for a few days after each session.
Who performs BPA?
BPA is performed by interventional radiologists and interventional cardiologists with specific training in pulmonary vascular procedures, working as part of a multidisciplinary CTEPH team that includes pulmonary hypertension specialists, cardiothoracic surgeons, hematologists, and cardiology.
